|
CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT D
|
Facility
|
IP
|
$610.00
|
|
|
Service Code
|
HCPCS 75573 TC
|
| Hospital Charge Code |
4220104
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$396.50 |
| Max. Negotiated Rate |
$396.50 |
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Galaxy Health Commercial |
$396.50
|
|
|
CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT D
|
Facility
|
OP
|
$610.00
|
|
|
Service Code
|
HCPCS 75573 TC
|
| Hospital Charge Code |
4220104
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$207.40 |
| Max. Negotiated Rate |
$1,036.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,036.00
|
| Rate for Payer: Aetna of NY Medicare |
$280.60
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$457.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$457.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$225.70
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$666.00
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: CDPHP Commercial |
$491.05
|
| Rate for Payer: CDPHP Medicare |
$225.70
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$427.00
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$488.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$488.00
|
| Rate for Payer: EmblemHealth Medicaid |
$488.00
|
| Rate for Payer: EmblemHealth Medicare |
$207.40
|
| Rate for Payer: EmblemHealth Select Care |
$396.50
|
| Rate for Payer: Fidelis Medicare |
$232.47
|
| Rate for Payer: Galaxy Health Commercial |
$396.50
|
| Rate for Payer: Hamaspik Choice Medicare |
$225.70
|
| Rate for Payer: Humana Medicare |
$225.70
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,036.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$280.60
|
| Rate for Payer: MVP Health Care of NY Commercial |
$457.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$343.43
|
| Rate for Payer: MVP Health Care of NY Medicare |
$236.98
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$775.00
|
| Rate for Payer: United Healthcare Commercial |
$775.00
|
| Rate for Payer: United Healthcare Medicare |
$225.70
|
| Rate for Payer: WellCare Medicare |
$335.50
|
|
|
CT LOWER EXTREMITY W/DYE
|
Facility
|
OP
|
$1,413.00
|
|
|
Service Code
|
HCPCS 73701 TC
|
| Hospital Charge Code |
4220027
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$480.42 |
| Max. Negotiated Rate |
$1,137.46 |
| Rate for Payer: Aetna of NY Commercial |
$1,036.00
|
| Rate for Payer: Aetna of NY Medicare |
$649.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1,059.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,059.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$522.81
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$666.00
|
| Rate for Payer: Cash Price |
$1,059.75
|
| Rate for Payer: Cash Price |
$1,059.75
|
| Rate for Payer: Cash Price |
$1,059.75
|
| Rate for Payer: CDPHP Commercial |
$1,137.46
|
| Rate for Payer: CDPHP Medicare |
$522.81
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$989.10
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,130.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,130.40
|
| Rate for Payer: EmblemHealth Medicaid |
$1,130.40
|
| Rate for Payer: EmblemHealth Medicare |
$480.42
|
| Rate for Payer: EmblemHealth Select Care |
$918.45
|
| Rate for Payer: Fidelis Medicare |
$538.49
|
| Rate for Payer: Galaxy Health Commercial |
$918.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$522.81
|
| Rate for Payer: Humana Medicare |
$522.81
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,036.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$649.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,059.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$795.52
|
| Rate for Payer: MVP Health Care of NY Medicare |
$548.95
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$775.00
|
| Rate for Payer: United Healthcare Commercial |
$775.00
|
| Rate for Payer: United Healthcare Medicare |
$522.81
|
| Rate for Payer: WellCare Medicare |
$777.15
|
|
|
CT LOWER EXTREMITY W/DYE
|
Facility
|
IP
|
$1,413.00
|
|
|
Service Code
|
HCPCS 73701 TC
|
| Hospital Charge Code |
4220027
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$918.45 |
| Max. Negotiated Rate |
$918.45 |
| Rate for Payer: Cash Price |
$1,059.75
|
| Rate for Payer: Galaxy Health Commercial |
$918.45
|
|
|
CT LOWER EXTREMITY W/O DYE
|
Facility
|
OP
|
$1,449.00
|
|
|
Service Code
|
HCPCS 73700 TC
|
| Hospital Charge Code |
4220025
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$492.66 |
| Max. Negotiated Rate |
$1,166.44 |
| Rate for Payer: Aetna of NY Commercial |
$1,036.00
|
| Rate for Payer: Aetna of NY Medicare |
$666.54
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1,086.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,086.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$536.13
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$666.00
|
| Rate for Payer: Cash Price |
$1,086.75
|
| Rate for Payer: Cash Price |
$1,086.75
|
| Rate for Payer: Cash Price |
$1,086.75
|
| Rate for Payer: CDPHP Commercial |
$1,166.44
|
| Rate for Payer: CDPHP Medicare |
$536.13
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,014.30
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,159.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,159.20
|
| Rate for Payer: EmblemHealth Medicaid |
$1,159.20
|
| Rate for Payer: EmblemHealth Medicare |
$492.66
|
| Rate for Payer: EmblemHealth Select Care |
$941.85
|
| Rate for Payer: Fidelis Medicare |
$552.21
|
| Rate for Payer: Galaxy Health Commercial |
$941.85
|
| Rate for Payer: Hamaspik Choice Medicare |
$536.13
|
| Rate for Payer: Humana Medicare |
$536.13
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,036.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$666.54
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,086.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$815.79
|
| Rate for Payer: MVP Health Care of NY Medicare |
$562.94
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$775.00
|
| Rate for Payer: United Healthcare Commercial |
$775.00
|
| Rate for Payer: United Healthcare Medicare |
$536.13
|
| Rate for Payer: WellCare Medicare |
$796.95
|
|
|
CT LOWER EXTREMITY W/O DYE
|
Facility
|
IP
|
$1,449.00
|
|
|
Service Code
|
HCPCS 73700 TC
|
| Hospital Charge Code |
4220025
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$941.85 |
| Max. Negotiated Rate |
$941.85 |
| Rate for Payer: Cash Price |
$1,086.75
|
| Rate for Payer: Galaxy Health Commercial |
$941.85
|
|
|
CT LUMBAR SPINE W/DYE
|
Facility
|
IP
|
$1,505.00
|
|
|
Service Code
|
HCPCS 72132 TC
|
| Hospital Charge Code |
4220030
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$978.25 |
| Max. Negotiated Rate |
$978.25 |
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: Galaxy Health Commercial |
$978.25
|
|
|
CT LUMBAR SPINE W/DYE
|
Facility
|
OP
|
$1,505.00
|
|
|
Service Code
|
HCPCS 72132 TC
|
| Hospital Charge Code |
4220030
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$511.70 |
| Max. Negotiated Rate |
$1,211.52 |
| Rate for Payer: Aetna of NY Commercial |
$1,036.00
|
| Rate for Payer: Aetna of NY Medicare |
$692.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1,128.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,128.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$556.85
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$666.00
|
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: CDPHP Commercial |
$1,211.52
|
| Rate for Payer: CDPHP Medicare |
$556.85
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,053.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,204.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,204.00
|
| Rate for Payer: EmblemHealth Medicaid |
$1,204.00
|
| Rate for Payer: EmblemHealth Medicare |
$511.70
|
| Rate for Payer: EmblemHealth Select Care |
$978.25
|
| Rate for Payer: Fidelis Medicare |
$573.56
|
| Rate for Payer: Galaxy Health Commercial |
$978.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$556.85
|
| Rate for Payer: Humana Medicare |
$556.85
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,036.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$692.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,128.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$847.32
|
| Rate for Payer: MVP Health Care of NY Medicare |
$584.69
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$775.00
|
| Rate for Payer: United Healthcare Commercial |
$775.00
|
| Rate for Payer: United Healthcare Medicare |
$556.85
|
| Rate for Payer: WellCare Medicare |
$827.75
|
|
|
CT LUMBAR SPINE W/O DYE
|
Facility
|
OP
|
$1,413.00
|
|
|
Service Code
|
HCPCS 72131 TC
|
| Hospital Charge Code |
4220028
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$480.42 |
| Max. Negotiated Rate |
$1,137.46 |
| Rate for Payer: Aetna of NY Commercial |
$1,036.00
|
| Rate for Payer: Aetna of NY Medicare |
$649.98
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1,059.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,059.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$522.81
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$666.00
|
| Rate for Payer: Cash Price |
$1,059.75
|
| Rate for Payer: Cash Price |
$1,059.75
|
| Rate for Payer: Cash Price |
$1,059.75
|
| Rate for Payer: CDPHP Commercial |
$1,137.46
|
| Rate for Payer: CDPHP Medicare |
$522.81
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$989.10
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,130.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,130.40
|
| Rate for Payer: EmblemHealth Medicaid |
$1,130.40
|
| Rate for Payer: EmblemHealth Medicare |
$480.42
|
| Rate for Payer: EmblemHealth Select Care |
$918.45
|
| Rate for Payer: Fidelis Medicare |
$538.49
|
| Rate for Payer: Galaxy Health Commercial |
$918.45
|
| Rate for Payer: Hamaspik Choice Medicare |
$522.81
|
| Rate for Payer: Humana Medicare |
$522.81
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,036.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$649.98
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,059.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$795.52
|
| Rate for Payer: MVP Health Care of NY Medicare |
$548.95
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$775.00
|
| Rate for Payer: United Healthcare Commercial |
$775.00
|
| Rate for Payer: United Healthcare Medicare |
$522.81
|
| Rate for Payer: WellCare Medicare |
$777.15
|
|
|
CT LUMBAR SPINE W/O DYE
|
Facility
|
IP
|
$1,413.00
|
|
|
Service Code
|
HCPCS 72131 TC
|
| Hospital Charge Code |
4220028
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$918.45 |
| Max. Negotiated Rate |
$918.45 |
| Rate for Payer: Cash Price |
$1,059.75
|
| Rate for Payer: Galaxy Health Commercial |
$918.45
|
|
|
CT LUMBAR SPINE W/O & W/DYE
|
Facility
|
OP
|
$1,598.00
|
|
|
Service Code
|
HCPCS 72133 TC
|
| Hospital Charge Code |
4220029
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$543.32 |
| Max. Negotiated Rate |
$1,286.39 |
| Rate for Payer: Aetna of NY Commercial |
$1,036.00
|
| Rate for Payer: Aetna of NY Medicare |
$735.08
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1,198.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,198.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$591.26
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$666.00
|
| Rate for Payer: Cash Price |
$1,198.50
|
| Rate for Payer: Cash Price |
$1,198.50
|
| Rate for Payer: Cash Price |
$1,198.50
|
| Rate for Payer: CDPHP Commercial |
$1,286.39
|
| Rate for Payer: CDPHP Medicare |
$591.26
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,118.60
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,278.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,278.40
|
| Rate for Payer: EmblemHealth Medicaid |
$1,278.40
|
| Rate for Payer: EmblemHealth Medicare |
$543.32
|
| Rate for Payer: EmblemHealth Select Care |
$1,038.70
|
| Rate for Payer: Fidelis Medicare |
$609.00
|
| Rate for Payer: Galaxy Health Commercial |
$1,038.70
|
| Rate for Payer: Hamaspik Choice Medicare |
$591.26
|
| Rate for Payer: Humana Medicare |
$591.26
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,036.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$735.08
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,198.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$899.67
|
| Rate for Payer: MVP Health Care of NY Medicare |
$620.82
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$775.00
|
| Rate for Payer: United Healthcare Commercial |
$775.00
|
| Rate for Payer: United Healthcare Medicare |
$591.26
|
| Rate for Payer: WellCare Medicare |
$878.90
|
|
|
CT LUMBAR SPINE W/O & W/DYE
|
Facility
|
IP
|
$1,598.00
|
|
|
Service Code
|
HCPCS 72133 TC
|
| Hospital Charge Code |
4220029
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,038.70 |
| Max. Negotiated Rate |
$1,038.70 |
| Rate for Payer: Cash Price |
$1,198.50
|
| Rate for Payer: Galaxy Health Commercial |
$1,038.70
|
|
|
CT LWR EXTREMITY W/O&W/DYE
|
Facility
|
IP
|
$1,505.00
|
|
|
Service Code
|
HCPCS 73702 TC
|
| Hospital Charge Code |
4220026
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$978.25 |
| Max. Negotiated Rate |
$978.25 |
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: Galaxy Health Commercial |
$978.25
|
|
|
CT LWR EXTREMITY W/O&W/DYE
|
Facility
|
OP
|
$1,505.00
|
|
|
Service Code
|
HCPCS 73702 TC
|
| Hospital Charge Code |
4220026
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$511.70 |
| Max. Negotiated Rate |
$1,211.52 |
| Rate for Payer: Aetna of NY Commercial |
$1,036.00
|
| Rate for Payer: Aetna of NY Medicare |
$692.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1,128.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,128.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$556.85
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$666.00
|
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: CDPHP Commercial |
$1,211.52
|
| Rate for Payer: CDPHP Medicare |
$556.85
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,053.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,204.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,204.00
|
| Rate for Payer: EmblemHealth Medicaid |
$1,204.00
|
| Rate for Payer: EmblemHealth Medicare |
$511.70
|
| Rate for Payer: EmblemHealth Select Care |
$978.25
|
| Rate for Payer: Fidelis Medicare |
$573.56
|
| Rate for Payer: Galaxy Health Commercial |
$978.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$556.85
|
| Rate for Payer: Humana Medicare |
$556.85
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,036.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$692.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,128.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$847.32
|
| Rate for Payer: MVP Health Care of NY Medicare |
$584.69
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$775.00
|
| Rate for Payer: United Healthcare Commercial |
$775.00
|
| Rate for Payer: United Healthcare Medicare |
$556.85
|
| Rate for Payer: WellCare Medicare |
$827.75
|
|
|
CT MAXILLOFACIAL W/DYE
|
Facility
|
OP
|
$1,239.00
|
|
|
Service Code
|
HCPCS 70487 TC
|
| Hospital Charge Code |
4220033
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$421.26 |
| Max. Negotiated Rate |
$1,036.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,036.00
|
| Rate for Payer: Aetna of NY Medicare |
$569.94
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$929.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$929.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$458.43
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$666.00
|
| Rate for Payer: Cash Price |
$929.25
|
| Rate for Payer: Cash Price |
$929.25
|
| Rate for Payer: Cash Price |
$929.25
|
| Rate for Payer: CDPHP Commercial |
$997.40
|
| Rate for Payer: CDPHP Medicare |
$458.43
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$867.30
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$991.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$991.20
|
| Rate for Payer: EmblemHealth Medicaid |
$991.20
|
| Rate for Payer: EmblemHealth Medicare |
$421.26
|
| Rate for Payer: EmblemHealth Select Care |
$805.35
|
| Rate for Payer: Fidelis Medicare |
$472.18
|
| Rate for Payer: Galaxy Health Commercial |
$805.35
|
| Rate for Payer: Hamaspik Choice Medicare |
$458.43
|
| Rate for Payer: Humana Medicare |
$458.43
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,036.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$569.94
|
| Rate for Payer: MVP Health Care of NY Commercial |
$929.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$697.56
|
| Rate for Payer: MVP Health Care of NY Medicare |
$481.35
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$775.00
|
| Rate for Payer: United Healthcare Commercial |
$775.00
|
| Rate for Payer: United Healthcare Medicare |
$458.43
|
| Rate for Payer: WellCare Medicare |
$681.45
|
|
|
CT MAXILLOFACIAL W/DYE
|
Facility
|
IP
|
$1,239.00
|
|
|
Service Code
|
HCPCS 70487 TC
|
| Hospital Charge Code |
4220033
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$805.35 |
| Max. Negotiated Rate |
$805.35 |
| Rate for Payer: Cash Price |
$929.25
|
| Rate for Payer: Galaxy Health Commercial |
$805.35
|
|
|
CT MAXILLOFACIAL W/O DYE
|
Facility
|
OP
|
$1,151.00
|
|
|
Service Code
|
HCPCS 70486 TC
|
| Hospital Charge Code |
4220031
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$391.34 |
| Max. Negotiated Rate |
$1,036.00 |
| Rate for Payer: Aetna of NY Commercial |
$1,036.00
|
| Rate for Payer: Aetna of NY Medicare |
$529.46
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$863.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$863.25
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$425.87
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$666.00
|
| Rate for Payer: Cash Price |
$863.25
|
| Rate for Payer: Cash Price |
$863.25
|
| Rate for Payer: Cash Price |
$863.25
|
| Rate for Payer: CDPHP Commercial |
$926.56
|
| Rate for Payer: CDPHP Medicare |
$425.87
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$805.70
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$920.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$920.80
|
| Rate for Payer: EmblemHealth Medicaid |
$920.80
|
| Rate for Payer: EmblemHealth Medicare |
$391.34
|
| Rate for Payer: EmblemHealth Select Care |
$748.15
|
| Rate for Payer: Fidelis Medicare |
$438.65
|
| Rate for Payer: Galaxy Health Commercial |
$748.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$425.87
|
| Rate for Payer: Humana Medicare |
$425.87
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,036.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$529.46
|
| Rate for Payer: MVP Health Care of NY Commercial |
$863.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$648.01
|
| Rate for Payer: MVP Health Care of NY Medicare |
$447.16
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$775.00
|
| Rate for Payer: United Healthcare Commercial |
$775.00
|
| Rate for Payer: United Healthcare Medicare |
$425.87
|
| Rate for Payer: WellCare Medicare |
$633.05
|
|
|
CT MAXILLOFACIAL W/O DYE
|
Facility
|
IP
|
$1,151.00
|
|
|
Service Code
|
HCPCS 70486 TC
|
| Hospital Charge Code |
4220031
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$748.15 |
| Max. Negotiated Rate |
$748.15 |
| Rate for Payer: Cash Price |
$863.25
|
| Rate for Payer: Galaxy Health Commercial |
$748.15
|
|
|
CT MAXILLOFACIAL W/O & W/DYE
|
Facility
|
IP
|
$1,332.00
|
|
|
Service Code
|
HCPCS 70488 TC
|
| Hospital Charge Code |
4220032
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$865.80 |
| Max. Negotiated Rate |
$865.80 |
| Rate for Payer: Cash Price |
$999.00
|
| Rate for Payer: Galaxy Health Commercial |
$865.80
|
|
|
CT MAXILLOFACIAL W/O & W/DYE
|
Facility
|
OP
|
$1,332.00
|
|
|
Service Code
|
HCPCS 70488 TC
|
| Hospital Charge Code |
4220032
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$452.88 |
| Max. Negotiated Rate |
$1,072.26 |
| Rate for Payer: Aetna of NY Commercial |
$1,036.00
|
| Rate for Payer: Aetna of NY Medicare |
$612.72
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$999.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$999.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$492.84
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$666.00
|
| Rate for Payer: Cash Price |
$999.00
|
| Rate for Payer: Cash Price |
$999.00
|
| Rate for Payer: Cash Price |
$999.00
|
| Rate for Payer: CDPHP Commercial |
$1,072.26
|
| Rate for Payer: CDPHP Medicare |
$492.84
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$932.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,065.60
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,065.60
|
| Rate for Payer: EmblemHealth Medicaid |
$1,065.60
|
| Rate for Payer: EmblemHealth Medicare |
$452.88
|
| Rate for Payer: EmblemHealth Select Care |
$865.80
|
| Rate for Payer: Fidelis Medicare |
$507.63
|
| Rate for Payer: Galaxy Health Commercial |
$865.80
|
| Rate for Payer: Hamaspik Choice Medicare |
$492.84
|
| Rate for Payer: Humana Medicare |
$492.84
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,036.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$612.72
|
| Rate for Payer: MVP Health Care of NY Commercial |
$999.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$749.92
|
| Rate for Payer: MVP Health Care of NY Medicare |
$517.48
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$775.00
|
| Rate for Payer: United Healthcare Commercial |
$775.00
|
| Rate for Payer: United Healthcare Medicare |
$492.84
|
| Rate for Payer: WellCare Medicare |
$732.60
|
|
|
CT NECK SPINE W/DYE
|
Facility
|
IP
|
$1,505.00
|
|
|
Service Code
|
HCPCS 72126 TC
|
| Hospital Charge Code |
4220009
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$978.25 |
| Max. Negotiated Rate |
$978.25 |
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: Galaxy Health Commercial |
$978.25
|
|
|
CT NECK SPINE W/DYE
|
Facility
|
OP
|
$1,505.00
|
|
|
Service Code
|
HCPCS 72126 TC
|
| Hospital Charge Code |
4220009
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$511.70 |
| Max. Negotiated Rate |
$1,211.52 |
| Rate for Payer: Aetna of NY Commercial |
$1,036.00
|
| Rate for Payer: Aetna of NY Medicare |
$692.30
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1,128.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,128.75
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$556.85
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$666.00
|
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: Cash Price |
$1,128.75
|
| Rate for Payer: CDPHP Commercial |
$1,211.52
|
| Rate for Payer: CDPHP Medicare |
$556.85
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,053.50
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,204.00
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,204.00
|
| Rate for Payer: EmblemHealth Medicaid |
$1,204.00
|
| Rate for Payer: EmblemHealth Medicare |
$511.70
|
| Rate for Payer: EmblemHealth Select Care |
$978.25
|
| Rate for Payer: Fidelis Medicare |
$573.56
|
| Rate for Payer: Galaxy Health Commercial |
$978.25
|
| Rate for Payer: Hamaspik Choice Medicare |
$556.85
|
| Rate for Payer: Humana Medicare |
$556.85
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,036.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$692.30
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,128.75
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$847.32
|
| Rate for Payer: MVP Health Care of NY Medicare |
$584.69
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$775.00
|
| Rate for Payer: United Healthcare Commercial |
$775.00
|
| Rate for Payer: United Healthcare Medicare |
$556.85
|
| Rate for Payer: WellCare Medicare |
$827.75
|
|
|
CT NECK SPINE W/O DYE
|
Facility
|
IP
|
$1,506.00
|
|
|
Service Code
|
HCPCS 72125 TC
|
| Hospital Charge Code |
4220020
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$978.90 |
| Max. Negotiated Rate |
$978.90 |
| Rate for Payer: Cash Price |
$1,129.50
|
| Rate for Payer: Galaxy Health Commercial |
$978.90
|
|
|
CT NECK SPINE W/O DYE
|
Facility
|
OP
|
$1,506.00
|
|
|
Service Code
|
HCPCS 72125 TC
|
| Hospital Charge Code |
4220020
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$512.04 |
| Max. Negotiated Rate |
$1,212.33 |
| Rate for Payer: Aetna of NY Commercial |
$1,036.00
|
| Rate for Payer: Aetna of NY Medicare |
$692.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$1,129.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$1,129.50
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$557.22
|
| Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$666.00
|
| Rate for Payer: Cash Price |
$1,129.50
|
| Rate for Payer: Cash Price |
$1,129.50
|
| Rate for Payer: Cash Price |
$1,129.50
|
| Rate for Payer: CDPHP Commercial |
$1,212.33
|
| Rate for Payer: CDPHP Medicare |
$557.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$1,054.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$1,204.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$1,204.80
|
| Rate for Payer: EmblemHealth Medicaid |
$1,204.80
|
| Rate for Payer: EmblemHealth Medicare |
$512.04
|
| Rate for Payer: EmblemHealth Select Care |
$978.90
|
| Rate for Payer: Fidelis Medicare |
$573.94
|
| Rate for Payer: Galaxy Health Commercial |
$978.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$557.22
|
| Rate for Payer: Humana Medicare |
$557.22
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$1,036.00
|
| Rate for Payer: Local 1199SEIU Medicare |
$692.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$1,129.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$847.88
|
| Rate for Payer: MVP Health Care of NY Medicare |
$585.08
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$775.00
|
| Rate for Payer: United Healthcare Commercial |
$775.00
|
| Rate for Payer: United Healthcare Medicare |
$557.22
|
| Rate for Payer: WellCare Medicare |
$828.30
|
|
|
CT NECK SPINE W/O & W/DYE
|
Facility
|
IP
|
$2,615.00
|
|
|
Service Code
|
HCPCS 72127 TC
|
| Hospital Charge Code |
4220008
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,699.75 |
| Max. Negotiated Rate |
$1,699.75 |
| Rate for Payer: Cash Price |
$1,961.25
|
| Rate for Payer: Galaxy Health Commercial |
$1,699.75
|
|
